MEASLES (Morbilli)

The measles virus is commonly spread by direct contact (droplet infection), particularly during the catarrhal stage of the illness, a stage at which measles is seldom diagnosed. Except for those who have previously suffered from the disease, susceptibility to measles appears to be practically universal. Although measles is always to be regarded seriously, it only constitutes a serious threat in the first 18 months of life when the complicating bronchopneumonia is a dangerous hazard.
In certain areas the first case of measles occurring in a household has to be notified to the Medical Officer of Health. Otherwise the disease is not notifiable. The incubation period is usually from nine to eleven days, but may vary from seven to fourteen days.
Preventive Treatment.—Passive Immunization.—An attack of measles can be prevented or modified by the intramuscular injection of an appropriate dose of gamma-globulin in the early stages of incubation. The dose of gamma-globulin cannot be stated with the accuracy associated with most biological products because the content of antibody is variable and there are minor variations in its preparation. For the child between one and three years of age the dose should be from 0-25 to 0-75 g. When given during the first few days of the incubation period such a dose will usually give complete protection, but when this is not attained, at least the subsequent attack is reduced in severity. The use of gamma-globulin should be restricted to contacts under the age of 18 months or children who are seriously debilitated, for example, after recovery from whooping-cough or pneumonia.
Active Immunisation.—Both a killed and a live attenuated virus vaccine are now available. The immunity obtained by the killed vaccine is of relatively short duration and a proportion of those inoculated with it acquire the disease at a subsequent exposure. The live attenuated virus vaccine produces a satisfactory immunity which certainly lasts for some years. The vaccine is freeze-dried and reconstituted with ro ml. of sterile distilled water before use. The injection is given subcutaneously. A proportion of the children inoculated (from 15-25 per cent.) develop moderately severe febrile reactions about a week after injection, while a few show evidence of a mild attack of measles. These reactions have been mitigated (a) by the simultaneous injection of gamma globulin and (&) by preliminary vaccination with the killed vaccine.
At present these vaccines are used mainly in those countries where the mortality from measles is high. In other communities where there are adequate standards of child health and where malnutrition is rare, measles is seldom a dangerous infection and prophylaxis by mass vaccination is hardly justifiable.
General Measures.—Contacts who have not previously suffered from measles are usually excluded from school for three weeks from the date of onset of the last case in the house. No restrictions need be applied to children who have previously suffered from measles. When measles is prevalent, susceptible children should not attend parties, the cinema or other gatherings. The prevention of exposure of children under eighteen months of age should be particularly impressed.
Curative Treatment.—General Management.—Isolation of the child at home is desirable although in the usual circumstances by the time the diagnosis is made the other children will generally have been infected. Since the main danger arises from secondary bacterial infection isolation will reduce the chances of such infection from without. The nursing of the child calls for no special measures apart from attention to the eyes, nose and mouth. In the early stages photophobia is often troublesome and makes screening of strong light desirable. When there is much conjunctivitis and blepharitis gentle cleansing with weak boric solution is useful and, after cleansing, the lids should be smeared with petroleum jelly to prevent sticking. The conjunctivitis usually clears in two to three days and if it persists the possibility of corneal ulceration should be considered. So far as the nose and mouth are concerned all that is required is frequent and gentle cleansing.
Tracheitis and laryngitis usually resolve quickly without treatment. In the young child or the adult they may give rise to more difficulty—in the former from partial obstruction of the airway and in the latter because of the substernal pain from coughing. Inhalation of steam with Friar's balsam is usually effective in relieving the child although occasionally tracheostomy is required. In the adult syrup of codeine phosphate or the elixir of methadone should be prescribed.
Prophylactic Chemotherapy.—Antibiotics have no therapeutic effect upon the virus stage of the infection. The patient is at risk only from secondary bacterial complications during the time that mucosal damage is being produced by virus. Once this period is past, convalescence is usually straightforward. Although the administration of antibiotics prophylactically as a routine during the early catarrhal stage seems desirable it is not recommended. With the form of measles now prevalent complications occur in a small proportion of cases and should be treated as they arise. Benzylpenicillin is effective in most cases as the commonest pathogens are Str. pyogenes and pneumococcus.
Complications.—Bronchopneumonia.—Bronchopneumonia is the most serious complication. Benzylpenicillin, given intramuscularly, should be the antibiotic of first choice and, when this treatment proves effective, it is often possible to change to oral preparations (p. 60).A mild degree of laryngitis is a common early symptom in measles. As a general rule laryngitis during the catarrhal stage is of virus origin and improves as the rash appears. When laryngitis arises after the appearance of the rash the possibility of diphtheritic infection should be kept in mind. If the child has not been immunized, a dose of 4,000 units of diphtheria antitoxin is desirable. Further treatment should be on the lines detailed on p. 671.
In the same way, gastroenteritis may be expected during the catarrhal or early rash stage as a natural part of the disease ; its occurrence, thereafter, should raise the immediate suspicion of dysentery. The possibility of acute appendicitis should not be forgotten.
Infection of the middle ear cleft is perhaps the most important complication as its careless management may leave the child with a chronic suppurative otitis media. Thus examination of the drumheads is an important part of the final clinical examination. Bacteriological examination of any aural discharge is essential so that an appropriate antibiotic—given systemically—may be chosen.
Acute encephalitis can occur with this as with other virus infections. Although a severe infection is not common, recent studies have indicated that mild encephalitis occurs much more frequently than was previously suspected. Indeed the remote possibility of encephalitis is one of the reasons for caution in the use of live measles virus vaccine. •
Convalescence.—In an uncomplicated case the child may be allowed out of bed about the fifth to seventh day from the onset of the disease, and out of isolation on the tenth day.
MENINGOCOCCAL INFECTIONS1
It is now clear that acute meningeal involvement must be regarded as only one form of meningococcal infection. Two other syndromes—acute fulminating septicaemia often with adrenal haemorrhage and chronic septicaemia usually unaccompanied by meningitis—are likely to be seen during epidemic periods ; indeed, the practitioner should have them especially in mind during the first and last two months of the year when the annual prevalence is at its height. For the recognition of both, the first essential is that the clinician remembers the possibility of their occurrence ; the features are sufficiently definite to permit a clinical diagnosis with a fair degree of accuracy. Although uncommon, attention is drawn to their existence, for in one—chronic septicaemia—correct treatment achieves rapid cure and may, in some cases, prevent subsequent meningitis ; while, in the other, only the most rapid diagnosis and immediate institution of proper measures hold out any possibility of recovery. The whole course from onset to death of a case of acute septicaemia with suprarenal haemorrhage may take but a few hours. In many fulminant cases of meningitis, too, the extensive nature of the skin haemorrhages suggests the possibility of suprarenal damage ; these cases should receive the appropriate treatment about to be described.
Such a concept of meningococcal infection is important because it draws attention to the mode of access of the meningococcus to the meninges. This route is—nasopharynx, blood stream, choroid plexus, meninges. Every case of meningococcal meningitis should be regarded as blood-borne. Treatment must thus be aimed not solely at the meninges but also at a systemic infection.1 All manifestations of infection by the meningococcus in Great Britain are notifiable under the general title " meningococcal infections It is perhaps because the sulphonamides can follow so closely the route of the meningococcus that they have proved more efficacious than penicillin.
Meningococcal infections are notifiable. The incubation period is from three to seven days.
Prevention and Epidemiological Control.—Carriers play an important part in the spread of the disease, and because of this it used to be regarded as valuable to search for carriers on the occurrence of a case. It is now appreciated that a simple routine examination of the nasopharynx on a single occasion may well fail to isolate the organism, although repeated examinations will often succeed. Indeed, in some carefully conducted studies it has been shown that practically all of the contacts were carrying the organism. This is especially the case in closed or semi-closed communities. Search for carriers has, therefore, been abandoned as a method of control. Fortunately, in the general population, case-to-case infection is not common and it is unusual to get more than one case in a household. In dormitories or army barracks the living—and particularly the recreational—accommodation should be reviewed. Measures for the control of dust such as wet-sweeping or oiling of floors are useful. It is probably true to say that the danger of overcrowded sleeping quarters and lecture halls is due as much to the periodic disturbance of dust by movement as to the actual close proximity of the inhabitants. Good ventilation is thus of great importance. It is possible that minor upper respiratory tract infections assist in the spread of meningococci, and in army camps, after a case has occurred, patients suffering from such complaints should be closely examined—especially if there is fever or a complaint of headache.
The administration of sulphonamides to contacts has a limited place when infection arises in a closed community. When this form of prophylaxis is used the doctor should be on the look-out for the re-appearance of organisms when treatment is stopped, for meningococci can develop sulphonamide resistance. Indeed penicillin-resistant strains are also encountered and, although they are uncommon, it should become increasingly the practice to test all meningococci isolated for their sensitivity to the common antibiotics.
Where the disease is epidemic in a community, it is well to remember that the highest attack rate is upon the child population under five years. The practitioner should take every opportunity to reinforce the advice given at these times by the Medical Officer of Health through the press. Crowded places should be avoided ; and the danger of sleeping in "overcrowded and badly ventilated rooms must be emphasized.